OIG Work Plan - July 2017 Updates

PUBLISHED: Jul 18, 2017
Relevant to: Critical Access Hospitals, Home Health, Hospice, Hospitals, Long Term Care

The Office of Inspector General (OIG) recently transitioned from annual to monthly Work Plan updates to ensure that it more closely aligns with the work planning process. The Work Plan gives health care organizations insight into areas where OIG is directing their attention and focus.

In their first monthly update, the following areas of focus are of interest:

  • Medicare Part B Payments for Ambulance Services Subject to Part A Skilled Nursing Facility Consolidated Billing Requirements: Medicare Part A prospective payments to skilled nursing facilities (SNFs) include most of the services that outside suppliers provide to SNF residents. Pursuant to 1862(a)(18) and 1842(b)(6)(E) of the Social Security Act, outside suppliers, including ambulance suppliers, must bill and receive payment from the SNF, not Medicare, for services provided to beneficiaries in SNF stays covered under Medicare Part A. Prior Office of Inspector General reports have identified high error rates and significant overpayments for services subject to SNF consolidated billing. OIG will determine whether ambulance services paid by Medicare Part B were subject to Part A SNF consolidated billing requirements. We will also assess the effectiveness of edits in CMS’s Common Working File to prevent and detect Part B overpayments for ambulance transportation subject to consolidated billing. Expected issue date FY2018.
  • High-Risk, Error-Prone HHA Providers Using HHA Historical Data: For Calendar Year 2016, Medicare paid home health agencies (HHAs) about $18.2 billion for home health services. CMS’s Comprehensive Error Rate Testing (CERT) program determined that the 2016 improper payment error rate for home health claims was 42 percent, or about $7.7 billion. Using data from the CERT program, OIG will identify the common characteristics of “at risk” HHA providers that could be used to target pre- and post-payment review of claims. Expected Issue date FY2018.
  • Nationwide Medicare Electronic Health Record (EHR) Incentive Payments to Hospitals: Previous OIG reviews of Medicaid EHR incentive payments found that State agencies overpaid hospitals by $66.7 million and would in the future overpay these hospitals an additional $13.2 million. These overpayments resulted from inaccuracies in the hospitals’ calculations of total incentive payments. OIG will review the hospitals’ incentive payment calculations to identify potential overpayments that the hospitals would have received as a result of the inaccuracies. Expected Issue date FY2018.
  • Review of Medicare Payments for Nonphysician Outpatient Services Provided under the Inpatient Prospective Payment System: Prior Office of Inspector General reviews identified significant overpayments to hospital outpatient providers for nonphysician services furnished shortly before or during inpatient stays. Recent OIG work indicated that providers are still billing inappropriately and contractors continue to make inappropriate payments for these nonphysician outpatient services. Additionally, Medicare payment system controls are not preventing or detecting overpayments for incorrectly billed services. OIG's objective is to determine whether nationwide Medicare payments to hospital outpatient providers were correct for nonphysician outpatient services provided within 3 days prior to the date of admission, on the date of admission, or during IPPS stays (excluding date of discharge). Expected Issue date FY2018.
  • Review of Medicare Payments for Telehealth Services: Medicare Part B covers expenses for telehealth services on the telehealth list when those services are delivered via an interactive telecommunications system, provided certain conditions are met (42 CFR § 410.78(b)). To support rural access to care, Medicare pays for telehealth services provided through live, interactive videoconferencing between a beneficiary located at a rural originating site and a practitioner located at a distant site. An eligible originating site must be the practitioner’s office or a specified medical facility, not a beneficiary’s home or office. OIG will review Medicare claims paid for telehealth services provided at distant sites that do not have corresponding claims from originating sites to determine whether those services met Medicare requirements. Expected Issue date FY2017.
  • Medicare Payments for Unallowable Overlapping Home Health Claims and Part B Claims: According to Section 1842 (b)(6)(F) of the Social Security Act, consolidated billing for all home health services is required while the beneficiary is under a home health plan of care authorized by a physician. The Act established a Medicare prospective payment system that pays home health agencies (HHA) for home services and covers all of their costs for furnishing services to Medicare beneficiaries. Pursuant to the home health consolidated billing requirements, the HHA that establishes a beneficiary’s home health plan of care has Medicare billing responsibility for services furnished to the beneficiary. Payment is made to the HHA whether or not the item or service was furnished by the HHA or by others by arrangement. OIG will review Medicare Part A payments to HHAs to determine whether claims billed to Medicare Part B for items and services were allowable and in accord with Federal regulations. Generally, certain items, supplies, and services furnished to inpatients are covered under Part A and should not be separately billable to Part B. Prior OIG audits, investigations, and inspections have identified this area for noncompliance with Medicare billing requirements. Expected Issue date FY2018.
  • Medicare Payments for Unallowable Overlapping Hospice Claims and Part B Claims: According to 42 CFR 418.24(d), a hospice beneficiary waives all rights to Medicare payments for any services that are related to the treatment of the terminal condition for which hospice care was elected or treatment of a related condition or treatment that is equivalent to hospice care. Excepted are those services provided by another hospice under arrangement or by an independent attending physician. The hospice agency assumes responsibility for medical care related to the beneficiary’s terminal illness and related conditions. When a service that is related to the hospice patient’s terminal illness is furnished by an outside provider, other than an independent attending physician, the provider must look to the hospice for payment. Medicare should not make a separate payment to the outside provider. Prior OIG audits, investigations, and inspections have identified this area for noncompliance with Medicare billing requirements. OIG will review Medicare Part A payments to hospices to determine whether claims billed to Medicare Part B for items and services were allowable and in accord with Federal regulations. Generally, certain items, supplies, and services furnished to inpatients are covered under Part A and should not be separately billable to Part B. Expected Issue date FY2018.

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